| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,613 |
6,610 |
$231K |
| D0120 |
Periodic oral evaluation - established patient |
7,636 |
7,633 |
$181K |
| D0274 |
Bitewings - four radiographic images |
4,668 |
4,668 |
$111K |
| D1206 |
Topical application of fluoride varnish |
4,062 |
4,054 |
$105K |
| D0220 |
Intraoral - periapical first radiographic image |
6,622 |
6,595 |
$87K |
| D1351 |
Sealant - per tooth |
1,400 |
759 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
804 |
536 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,810 |
3,809 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,067 |
4,684 |
$42K |
| D1110 |
Prophylaxis - adult |
780 |
780 |
$39K |
| D1354 |
|
871 |
418 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
503 |
377 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
366 |
213 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
527 |
522 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
926 |
924 |
$4K |
| D9995 |
|
137 |
134 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
14 |
$2K |
| D0240 |
|
67 |
55 |
$2K |
| D0272 |
Bitewings - two radiographic images |
117 |
117 |
$1K |
| D1320 |
|
171 |
171 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$497.28 |
| D0250 |
|
18 |
18 |
$369.45 |